A panel of experts published new recommendations for assessing and managing CVD risk while treating patients with prostate cancer.
The Prostate Cancer Cardiovascular (PCCV) Expert Network recently published recommendations to guide prostate cancer care strategies. The guidance centers on how clinicians can assess cardiovascular disease (CVD) risk and implement multidisciplinary care for their patients.
“The European Society of Cardiology (ESC) 2022 Guidelines on Cardio-Oncology recommend gonadotropin-releasing hormone antagonists for patients with pre-existing coronary artery disease who require androgen deprivation therapy,” wrote Axel S. Merseburger, MD, PhD, lead author, and colleagues. “However, real-world data show that gonadotropin-releasing hormone antagonists are not widely adopted in practice, indicating a gap between guidelines and practice that should be bridged by prioritizing cardioprotection.”
The team of experts included 14 urologists, three cardiologists, and one medical oncologist. They identified the following barriers to routine CVD risk assessment and management:
- lack of awareness regarding cardiovascular toxicities associated with androgen deprivation therapy (ADT);
- the need for timely initiation of ADT;
- challenges in using risk assessment tools in busy clinical practice; and
- difficulties in involving cardiologists in prostate cancer treatment planning.
With these barriers in mind, the PCCV Expert Network proposed several strategies to improve CVD risk stratification and management.
“It is important to note that the recommendations presented herein are supported by general agreement amongst experts rather than a formal assessment of consensus,” Dr. Merseburger and team wrote.
CVD Risk Assessment Tools
While the ESC Guidelines recommend using SCORE2 or SCORE2-OP for CVD risk assessment, the authors advised that clinicians may also use the Framingham Risk Score, ESC HeartScore, QRISK 3, JBS3 risk calculator, and the
American College of Cardiology/American Heart Association Atherosclerotic Cardiovascular Disease Risk Estimator.
“The routine adoption of these existing cardiovascular risk calculators is hindered by the perception that these tools are cumbersome and may not be practical for busy urologists. Instead, urologists mainly rely on subjective cardiovascular health assessment (eg, eye-balling) during in-clinic physical examination, which involves evaluation of medical history and symptoms,” authors noted.
To address this gap, experts created a simplified checklist that may be integrated into routine care. Clinicians can use it to stratify patients into low, intermediate, or high CVD risk, depending on their history of CVD events and the presence of risk factors such as diabetes or smoking history.
For greater ease of use, providers can print the checklist for patients and their caregivers to fill out while in the waiting room. Checklists should be written in plain language and offered in local languages so patients can understand them, the panel advised.
“It is recommended that urologists conduct CVD risk assessment and stratification before initiating ADT treatment,” Dr. Merseburger and colleagues said. “However, patients with ongoing ADT treatment may also benefit from CVD risk assessment because elevated risk may warrant medication review.”
Guidance for Treating Patients With CVD Risk
The experts also included a checklist with management steps for minimizing cumulative CVD risk when starting patients on ADTs.
Patients with low CVD risk should initiate ADT as soon as possible. For patients with intermediate or high risk, Dr. Merseburger and colleagues advise clinicians to optimize risk factors before, during, and after cancer treatment.
Patients with active cardiac symptoms may be referred to a cardiologist prior to initiating treatment. Gonadotropin-releasing hormone (GnRH) antagonists are preferred for patients with pre-existing CVD, experts said.
“As evidence suggests that GnRH antagonists are associated with lesser risk of CV toxicities than those of GnRH agonists, GnRH antagonists should be considered to minimize cumulative cardiovascular risk of combination treatment,” the authors wrote.
Risk Management in the Multidisciplinary Team
In addition, the panel offered guidance for managing CVD risk within a multidisciplinary care team. They recommended clinicians use an ABCDE approach: risk assessment, blood pressure control, cholesterol management, diabetes care, and tailored exercise prescription.
General practitioners or family physicians can conduct annual assessments for patients with low-to-intermediate CVD risk. These providers can also monitor patient adherence to the team’s cardiovascular health plan.
“If a patient experiences a cardiovascular event or exhibits abnormalities during cardiovascular assessment, the general practitioner or family physician should inform the urologist, as it may necessitate a medication review and referral to a cardiologist,” the authors advised.
A cardiologist may recommend specialized monitoring and care for patients with high CVD risk. In this case, relevant specialists on the team should create a new plan to monitor the patient for cancer recurrence and cardiovascular health.
Authors called for further research to assess these management strategies in a real-world setting, adding that “medical education emphasizing the feasibility of CVD risk assessment and mitigation in routine [prostate cancer] care may enhance the adoption of these practices.”
“Raising awareness of cardiovascular risk factors and implementing routine risk assessment during consultations are essential components of long-term management of [prostate cancer],” Dr. Merseburger and colleagues said.
Click here to read more about the panel’s recommendations.
